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Topic: WORKERS' COMPENSATION CLAIMS

INVESTIGATION/ADMINISTRATION Date Issued: June 29, 1994

Section: WORKERS' COMPENSATION Date Revised:

Number: XXI.3.

PURPOSE:

To provide County departments with an understanding of the process involved

in determining eligibility for Workers' Compensation benefits.

LEGAL BASIS:

Division 4 of the Labor Code of the State of California, and California

Civil Code, Part 2.6, Chapter 2, Section 56.10(c)(8)(A)

POLICY:

I. The County is mandated by the State to provide specified benefits to

employees with work-related injuries.

II. The definition of a work-related injury is an injury which arises out

of employment (AOE) and/or occurs in the course of employment (COE).

Each claim for Workers' Compensation benefits must be reviewed to

determine whether it meets these criteria. If the information provid-

ed on the injury reports is unclear, steps must be taken to gather

sufficient information to make this determination. This section out-

lines procedures followed by Risk Management and the Workers' Compen-

sation claims administrator in gathering the data needed to either

directly determine eligibility, or to provide to a medical evaluator

who will make this determination.

PROCEDURE:

I. Claims Review and Followup

When Risk Management receives the required documents supporting a

Workers' Compensation injury, the documents are first reviewed for

completeness and proper signatures. The documents would include orig-

inals of Employee's Claim for Workers' Compensation Benefits; Supervi-

sors' Report of Accident and, if the employee received medical atten-

tion and/or lost work time, the Employer's Report of Occupational

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Injury/Illness. If the injury and causation are described in suffi-

cient detail to leave no doubt that the injury happened at work and

appears to have a connection to work duties (example: a Building

Maintenance Worker who cut his/her hand while repairing a broken win-

dow), Risk Management forwards the paperwork to the claims administra-

tor without further action.

II. Questionable Claims

In some cases, the relationship of the injury to the job is unclear.

An example of this would be an office worker who has been on vacation

for two weeks, who files a Workers' Compensation claim on the morning

s/he returns, reporting fever, sore throat and nasal congestion which

s/he claims are the result of the air handling system. In this case,

Risk Management would check with the supervisor to confirm there had

not been any ventilation problems that morning in that work area, and

relay that information, along with the claim, to the claims adminis-

trator. The claims administrator would send a notice to the employee

that his/her claim was being delayed, and request that s/he provide

medical documentation to support his/her claim. Ultimately, in a case

of this type, medical records would determine whether the work envi-

ronment caused the injury. In the absence of a positive work connec-

tion, this claim would be denied.

A. Stress Claims

Stress claims are a special type of questionable claim. They are

automatically considered questionable because, unlike the Build-

ing Maintenance Worker who was cut on a piece of window glass,

it is difficult to determine the cause, or even if there is an

injury. Current Workers' Compensation laws require that actual

events of employment must be the predominant cause of the psychi-

atric injury. This means that personal factors, as well as

work-related issues, must be included in the data gathered to

make a determination. All stress claims, unless the cause was

clearly a traumatic work event (such a being a victim of a vio-

lent act, or from direct exposure to a significant violent act),

will be fully investigated.

1. To assist the claims administrator in evaluating the claim,

the supervisor completing the Supervisor's Report of Acci-

dent should attach a memo outlining any relevant informa-

tion, or send the memo separately in a CONFIDENTIAL envelope

to Risk Management.

2. Risk Management will contact the department personnel liai-

son to gather information and determine which staff members

should be interviewed by the outside claims investigator.

3. The claims administrator will contact the claimant to find

out the circumstances surrounding the claim, and explain the

process for investigating a Workers' Compensation stress

claim. The claims administrator will mail the claimant a

notice that benefit determination is delayed pending inves-

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WORKERS' COMPENSATION CLAIMS INVESTIGATION/ADMINISTRATION Page 3 of 3

tigation, that the claimant may be contacted by an outside

claims investigator, and that final determination will be

made within 90 days. They will also send the claimant a

medical release to complete and return, so that they can

request records from all medical providers consulted by the

employee over the past five years.

4. The claims investigator will take statements from the claim-

ant, claimant's supervisor, and co-workers having knowledge

of the claimant's work and personal situation. Records in

the claimant's departmental personnel file and central per-

sonnel file in the Personnel Department will be copied to be

included with the investigator's report. The County pre-

employment physical records will also be requested.

5. The claimant is then scheduled for a psychiatric evaluation

with a specialist knowledgeable in criteria for evaluating

Workers' Compensation stress claims. This evaluator will

review all medical records, the investigative report, and

any other pertinent information, and perform a comprehensive

psychiatric evaluation of the claimant before issuing a

written report. If the evaluator finds that work factors

(other than "lawful, non-discriminatory, good faith person-

nel actions") represented less than the preponderance of

causation, the claims administrator will send a notice of

denial of benefits. If the evaluator feels the claim is

compensable, benefits will be paid retroactive to the first

day of disability.

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